Provider Demographics
NPI:1588988950
Name:ILIZAROV, SEMEN K
Entity type:Individual
Prefix:MR
First Name:SEMEN
Middle Name:K
Last Name:ILIZAROV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9305 63RD DR
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2924
Mailing Address - Country:US
Mailing Address - Phone:718-459-3370
Mailing Address - Fax:718-459-2074
Practice Address - Street 1:9305 63RD DR
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2924
Practice Address - Country:US
Practice Address - Phone:718-459-3370
Practice Address - Fax:718-459-2074
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045234183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist